Scaling up of STI services in the third phase of National AIDS Control Program of India

ABSTRACT ID : ICAAP1400-00448

Sugata Mukhopadhyay

Issue: STIs are the major co-factors of HIV transmission. An estimated 30 million of STI episodes occur in India. The third phase of National AIDS Control Program of India targeted to reach about 10 million STI episodes annually.

Project or Activities: Designated STI/RTI clinics increased from 916 in 2008-09 to 1112 in 2011-12. 45 national and 587 state resource faculties from all states were trained on STI management by National AIDS Control Organization (NACO) of India during 2007-08. Those resource persons trained 2224 healthcare providers in 2008, 7511 in 2009, 5224 in 2010 and 6496 in 2011. 7 STI training, reference and research centres were established to augment training and research in STI case management across the country. In 2007, STI Clinics were branded as Suraksha clinic within the National Communication Strategy on STI/RTI Service Delivery. 776 STI counselors were appointed in the program in 2007-08 which was scaled up to 955 in 2011-12. Preferred private providers who treat HRGs in their localities for STIs were identified and trained on national STI treatment protocol, 5744 in 2009-10, 3891 in 2010-11 and 3942 in 2011-12. Pre-packed colour coded STI/RTI kits were provided for free supply at all designated STI/RTI clinics.

Results: 2.6 million, 6.67 million, 8.49 million and 10 million (till Jan’12) STI episodes were treated in 2008, 2009, 2010 and 2011 respectively. HRG members who had been treated for STIs showed gradual increase from 158,973 in 2007 to 632,151 in 2008 and to 1,057,577 in 2009. It was also observed that number of STI/RTI cases in HRGs declined from first to third quarter of 2011-12 by 2.5% though the clinic attendance went up to 18%. During April-June, 2011 38.5 percent of HRG had utilized regular medical check-up services of TI (Targeted Intervention) clinics which increased to 45.9% during Oct.-Dec 2011 showing improvement in health-seeking practices in HRGs. Though syphilis testing has improved but still below 40 percent against the target as country average.

Lessons learned: : India’s experience is one of the most prominent examples of scaling up of STI services through optimal resource allocation and strategic implementation of action plan of STI control. (Selected for E-POSTER)

Child sexual abuse in India – a situation analysis

Author: Sugata Mukhopadhyay

Background:  19% percent of the world's children live in India, which constitutes 42 percent of India’s total population (430 million). The government estimates that 40 percent of India's children vulnerable to sexual abuse, trafficking, homelessness, forced labor, drug abuse, and crime, so needs protection.

Methods: The abstract aims to do a situation analysis of child sexual abuse in India by collecting relevant information including case-studies through net-surfing, interviewing local NGOs working to protect children and interacting with some abused children. 

Results: The ‘Study on Child Abuse: India 2007’ of Govt. of India sampled 12447 children, 2324 young adults and 2449 stakeholders across 13 states with the following key findings:  53.22% of children reported sexual abuse. Among them 52.94% boys and 47.06% girls. Andhra Pradesh, Assam, Bihar and Delhi reported highest percentage and incidence of sexual abuse. 21.90% of children faced severe forms of sexual abuse, 5.69% sexually assaulted and 50.76% reported other forms of sexual abuse. Children on street, at work and in institutional care reported the highest incidence of sexual assault. 50% of abusers were known to the child or are in a position of trust and responsibility. 94% children had not reported to anyone.

According to studies conducted by Civil Society Organization,

·         9000 children estimated to go missing annually

·         500,000 children estimated to be forced into sex trade annually

·         Children form 40% of total commercial sex workers’ population

·         80% of these children found in the five metros – Delhi, Mumbai, Kolkata, Chennai, Bangalore

·         71% illiterate.  

Conclusion: Recent rapid rise of child abuse cases across the country is the outcome of escalating degradation of social values and growing desperateness to make mockery of law and administration. The crisis should be responded with large scale advocacy & social awareness to restore children’s rights and exemplary judicial decisions against abusers. 

(Selected for poster presentation in SVRI Forum 2013 (14 - 17th Oct'13, Bangkok, Thailand) 

UGLY CIRCUMCISION RITUAL TREND IN SOUTH AFRICA

Uchenna Anozie,
Nigeria

Male circumcision (from Latin circumcidere, meaning "to cut around") is the surgical removal of the foreskin (prepuce) from the human penis. In a typical procedure, the foreskin is opened and then separated from the glans after inspection.

This procedure is obtainable in many races of the world and it was on biblical record that circumcision is a sign of covenant between the Israelites and Yahweh. Apart from the Jews other races practice this, especially African races.In the western world circumcision is done at childhood and done medically with anaesthesia in some cases, this medical procedure is safe and sound without any negative impact, and in fact recent discoveries show that circumcised males stand a reduced risk of contracting HIV than the uncircumcised.

Other sources confirmed that women prefer men with circumcised penis than the uncircumcised penis, reason being that the uncircumcised penis has an ugly aesthetic view and often very pointed, well there is no theory that proves to us which penis is better.

It will interest us to know that various races round the world see circumcision as a ritual but today I am going to focus on South Africa where this ritual of male circumcision is taken serious and it is becoming a public health concern because  lot of lives have been lost in this ritual performances while some males have permanently lost their penis or are still battling with a rotten penis due to acquired infections associated with their procedure of circumcision. Also HIV has been a great concern because unsterilized instruments are used during these rituals.

According to inquirerdotnet, Agence France-Presse. Monday, July 8th, 2013. Botched circumcisions killed 30 young men and landed almost 300 more in hospital during traditional initiation rites in a South African province, the health department said Sunday.

The 30 deaths in rural Eastern Cape province occurred during the annual season when young males undergo a rite of passage into manhood.

Ten other youths were hospitalized after being rescued from a forest on Sunday, said provincial health department spokesman SizweKupelo in a statement.

“The ten initiates’ private parts are rotten. They are badly damaged. Their condition is scary,” he said.

A further 293 young men were undergoing hospital treatment for dehydration, gangrene and septic wounds, Kupelo added.

Some had lost their genitals.

Teenagers from ethnic Xhosa, Sotho and Ndebele groups typically spend around a month in secluded bush or mountains areas for their initiation to manhood.

This includes a circumcision as well as lessons on masculine courage and discipline.

Traditional surgeons perform the procedure in the bush, sometimes with unsterilized instruments or lacking in technique.

Botched circumcisions leading to penis amputations and deaths are an annual tragedy.

In May around 34 deaths in two other provinces were reported.

Needless giving more history on these sad events, it has been a regular occurrence in South Africa but the question is what can we do about this public health problem, this is an ugly trend and yet we need to respect people’s culture and tradition.

We public health activists should do our best to convince the south African government to carry out a strong advocacy on safer ways of practicing this circumcision ritual, it will be better off if these males are circumcised as children, not waiting till the grow up to 16 years and above. Also if medical practitioners are involved in the procedure with anaesthesia and sterilized instruments being used, then we can encourage this ritual, but these traditional surgeons are endangering people lives, young and promising fellows. It has been reported severally that people witch hunt their enemies during these ritual by doing a bad procedure on the children of their presumed enemies.

Let us spread this campaign and who knows the South African government might have the political will to face this ugly ritual trend.

Mahila Mandals: Case Studies from Mumbai, India

Sarah Simpson, University of Medicine & Dentistry of New Jersey, MPH-Epidemiology Candidate

Home to more than 18 million people, India’s most populous city, Mumbai, continues to be an attraction for millions looking for a better life for themselves and their families. Migrants from different parts of India, religions and cultures end up in the crowded slum communities around Mumbai. This past winter I had the opportunity to learn about urban health issues in these slum communities along with 20 other students from around the US and the world for three weeks at the Tata Institute of Social Sciences (TISS) in Mumbai.

My project group and I sped around town in rickshaws, trudged through sludge, and dust to study urban health issues in the slum areas of Shivaji Nagar.  Located in the M Ward and home to some of the largest slums in India, about 600,000 people live in this area, which is located near the Deonar dumping ground, a man-made mountain of debris and trash. The health of the urban poor is complicated by many issues ranging from waterborne illnesses to infectious and communicable diseases, and when compounded by inadequate nutrition and overcrowded and poorly constructed living conditions makes for a dire situation for millions of people.

During our first day, we were introduced to the “Mahila Mandals” or women’s groups there are instrumental to addressing these public health issues.  Parts of Shivaji Nagar are plotted slum areas recognized by the government; however they have minimal access to facilities and services provided by the Brihanmumbai Municipal Corporation (BMC). Imagine sharing 28 bathroom stalls (14 for men, 14 for women) with 1,000 other people and as you can imagine they quickly become unsanitary. The breakdown of government services has lead to the organization of community based organizations such as Mahila Mandals.

Instead of using a needs-based or problems-focused approach which would highlight only the worse aspects of a community, we decided to highlight the community’s assets by writing a case study using SWOT (Strengths, Weakness, Opportunities and Threats) Analysis to help us investigate how to best utilize these important community assets. We interviewed 6 Mahila Mandal groups consisting of some registered and unregistered groups and varying in size and number of members.  We concluded that not only do the Mahila Mandals work to solve issues with sanitation, but they also promote immunization of children, maternal and child health education and resolve domestic violence issues. However, their impact is limited mostly due to funding and support from the local community.

At the end of our study, we recommended that the government provide more funding and implement community-based participatory research programs which would allow the communities to identify, support, and mobilize existing resources to create a shared vision of change and encourage greater creativity in solving community issues.² Community organizations like these groups and community engagement are important for continued public health and social change. Further research is needed on how to best utilize these valuable community assets.

Our internship presentation can be found at: http://prezi.com/i0lbgveimbyc/copy-of-indian-urban-slums/

References:

1. Mili, D. Migration and Healthcare Access to Healthcare Services by Migrants Settled in Shivaji Nagar Slum of Mumbai, India. TheHealth 2011; 2(3): 82-85 

Polio eradication is achievable by 2018 and urgent, declare 400+ global scientists

Experts from 80 countries cite time-limited opportunity, endorse comprehensive new eradication strategy

Hundreds of scientists, doctors and other experts from around the world launched the Scientific Declaration on Polio Eradication today, declaring that an end to the paralyzing disease is achievable and endorsing a comprehensive new strategy to secure a lasting polio-free world by 2018. The declaration's launch coincides with the 58th anniversary of the announcement of Jonas Salk's revolutionary vaccine.

 

The more than 400 signatories to the declaration urged governments, international organizations and civil society to do their part to seize the historic opportunity to end polio and protect the world's most vulnerable children and future generations from this debilitating but preventable disease. The declaration calls for full funding and implementation of the Polio Eradication and Endgame Strategic Plan 2013-2018, developed by the Global Polio Eradication Initiative (GPEI). With polio cases at an all-time low and the disease remaining endemic in just three countries, the GPEI estimates that ending the disease entirely by 2018 can be achieved for a cost of approximately $5.5 billion.

 

"We have the tools we need and a time-limited opening to defeat polio. The GPEI plan is the comprehensive roadmap that, if followed, will get us there," said Dr. Walter Orenstein, professor and associate director of the Emory Vaccine Center at Emory University and former director of the U.S. Centers for Disease Control and Prevention's National Immunization Program. Dr. Orenstein is one of the scientists spearheading the declaration and among the signatories who were on the frontlines of ending smallpox, the only human disease to be successfully eradicated.

 

The declaration – housed online by Emory University at vaccines.emory.edu/poliodeclaration – notes that polio vaccines have already protected hundreds of millions of children from the disease and eliminated one of the three types of wild poliovirus, proving that eradication is scientifically feasible. It calls on the international community to meet the goals in the GPEI plan for delivering polio vaccines to more children at risk, particularly in Afghanistan, Nigeria and Pakistan, where polio remains endemic and emergency action plans launched over the past year have resulted in significant improvements in vaccine coverage.

 

"Securing a lasting polio-free world goes hand in hand with strengthening routine immunization. We need all countries to prioritize investments in routine immunization," said Dr. Zulfiqar Bhutta, founding director of the Center of Excellence in Women and Child Health at Aga Khan University. Dr. Bhutta, one of the declaration's leaders, is a member of the Strategic Advisory Group of Experts (SAGE) on Immunization, a technical advisory body to the GPEI.

 

The declaration emphasizes that achieving polio eradication requires efforts interrelated with strengthening routine immunization, a new focus of the GPEI plan. As the last cases of polio are contained, high levels of routine immunization will be critical. At the same time, resources and learning from polio eradication efforts can be used to strengthen coverage of other life-saving vaccines, including for children who have never been reached with any health interventions before.

 

The scientists and experts signing the declaration called on the international community to take steps outlined in the GPEI plan to address challenges that have posed obstacles to polio eradication in the past, including improving immunization campaign quality to reach missed children and eliminating rare polio cases originated by the oral polio vaccine. While previous polio efforts have sought to interrupt wild virus transmission and then address vaccine-derived virus, the new GPEI plan addresses both simultaneously with a timetable to phase out use of oral polio vaccines and introduce inactivated polio vaccines. The declaration urges vaccine manufacturers to provide an affordable supply of the different vaccines required for eradication, and calls on scientists to continue researching new and better tools.

 

"As long as it exists anywhere in the world, polio threatens children everywhere," said Professor Helen Rees, executive director of the Wits Reproductive Health and HIV Institute at the University of the Witwatersrand in South Africa, who signed the declaration and chairs SAGE. "By pursuing in parallel all of the steps needed to reach eradication, including the introduction of inactivated vaccines, countries have a complete path to eliminate polio's threat." In November 2012, SAGE recommended the introduction of at least one dose of inactivated polio vaccine into all routine immunization programs prior to the phase-out of oral polio vaccines.

 

In light of recent attacks on health workers in some endemic countries, the declaration stresses the need to protect polio vaccination teams as they do their work. The GPEI plan includes a series of risk-mitigation strategies for insecure areas, including deepening engagement with community and religious leaders.

 

The scientists and experts signing the declaration hail from 80 countries and include Nobel laureates, vaccine and infectious disease experts, public health school deans, pediatricians and other health authorities. More than 40 leading universities and schools of public health and medicine are promoting the declaration on their websites, including Aga Khan University, the Harvard School of Public Health, the London School of Hygiene & Tropical Medicine, Al Azhar University (Egypt), University of Cape Town, Redeemer's University (Nigeria) and Christian Medical College Vellore (India).

 

The declaration notes that the world has a unique window of opportunity to eradicate polio. Only 223 new cases due to wild poliovirus were recorded in 2012, an historic low and a more than 99 percent decrease from the estimated 350,000 cases in 1988. Just 16 new cases have been reported so far in 2013 (as of 9 April). India, long-regarded as the most difficult place to eliminate polio, has not recorded a case in more than two years.

 

"Eradicating polio is no longer a question of technical or scientific feasibility. Rather, getting the most effective vaccines to children at risk requires stronger political and societal commitment," said Dr. David Heymann, head and senior fellow at the Chatham House Centre on Global Health Security and a signatory of the declaration. "Eliminating the last one percent of polio cases is an immense challenge, as is the eradication endgame after that. But by working together we can make history and leave the legacy of a polio-free world for future generations."

(Source   EurelekAlert-Public- release-13  April 2013/Global Health Strategies)

 

Foussénou    Sissoko

Health   Communication  Expert

sissokofouss@yahoo.fr

Prevention of DR-TB.......a fantasy

Prevention of DR-TB – I am yet to understand if there is any such agenda  in TB program or it is just a fantasizing imagination? The amount of efforts we put in creating hue and cry over DR-TB, probably we don’t even invest 10% of that energy and emotion to advocate for DR-TB prevention.

Does it mean DR-TB is an unpreventable illness?

There is no scientific evidence that said so. DR-TB is preventable. It is said to be a man-made phenomena and requires quality implementation and monitoring of the basic activities that can ensure drug adherence and timely treatment completion by the TB patients enrolled in the national program.

In public health programs 'basic' interventions often bypass due attention of the managers and activists.

A notable example is patient-provider meetings. These meetings were introduced into national TB control initiative as the key platform of TB patients’ education and treatment compliance that can further lead to effective community-facility collaboration.

Can anyone of this forum share the experiences of a patient-provider meeting? How the quality of such meetings is being ensured? What outputs and outcomes are expected from these meetings? What indicators are being used to monitor these activities? Any relevant case study showing expected results?

I believe I am asking for too much.

Sometimes I feel we are just inviting DR-TB to perish us.

Exactly the way, HIV was combated with poorly organized prevention strategies and tools, especially in Sub-Saharan Africa, decades ago.

   

We already saw the result of that.

Extra-couple sex is key HIV transmission factor in Africa

News From Foussénou  Sissoko
Health Communication Expert

  Extra-couple HIV transmission — infections from sexual intercourse taking place outside an established partnership — continue to fuel new HIV infections among heterosexual couples in Sub-Saharan Africa, according to a study.

In some countries, up to 65 per cent of new infections among men in co-habiting relationships are due to extra-couple intercourse. 

SPEED READ

·         Study analyses HIV tests of 27,000 cohabiting couples in Sub-Saharan Africa

·         Up to 65 per cent of men contract HIV through extra-couple intercourse

·         Study recommends HIV interventions for all sexually active people, not just 'at risk' groups

Scientists analysed the HIV tests of 27,000 cohabiting couples from 18 African countries. They found extra-couple transmissions to be a common contributing factor for new HIV infections in the region and that the transmissions within couples occur largely from men to women.

For this reason, the authors advocate HIV prevention interventions for the entire sexually active population, not just couples where one partner is HIV-positive.

Sub-Saharan Africa is home to around 22.9 million people living with HIV/AIDS — the majority of the 34 million infected people worldwide — and registers the highest number of HIV-related deaths annually, according to the WHO.

Steve Bellan, a post-doctoral researcher at the University of Texas and the study's lead author, tells SciDev.Net that the research team wanted to identify how many people were infected with HIV before entering their current relationship; how many were infected by their official partner; and how many by extra-couple intercourse.

"Extra-couple transmission within stable, cohabiting couples was responsible for new HIV infections among an overwhelming 32-65 per cent of men and 10-47 per cent of women — varying according to country," Bellan says.

He says that individual country analyses gave wide-ranging results relating to the percentage of transmissions due to extra-couple intercourse.

Bellan was unable to say if the study's findings were typical of Africa only, but he called for further research to enable a comparison of world regions.

The study, published online in The Lanceton 5 February, proposes certain measures to help curb the epidemic, such as early and proper antiretroviral treatments.

Couples should also be offered the opportunity to get tested, receive their results and mutually disclose their status in a supportive counselling environment, the study says, as this will aid treatment and prevention.

It also recommends expanding treatment, whereby all infected individuals should be given immediate early treatment on a 'test and treat concept' basis.

Alloys Orago, director of Kenya's National AIDS Control Council, tells SciDev.Net: "Since 2008, we have been advocating for a reduction in the number of sexual partners and being faithful to a single, uninfected sexual partner as a tool in HIV prevention".

"HIV prevention should target everybody, not just populations perceived to be most at risk, because HIV knows no boundaries," he concludes. 

  Link to study abstract in The Lancet

(Source  : SciDev.Net's Sub-Saharan Africa desk.)

Syndromic Management of STI - one slide presentation to be attached to the STI Clinic (for easy reference of the clinic doctors)

Sugata Mukhopadhyay
Universal Health

WORLD TB DAY 2013 - MESSAGE OF UNIVERSAL HEALTH

Bangladesh makes dramatic advances in child survival.

In 1990, the infant mortality rate in Bangladesh, 97 deaths per 1,000 live births, was 16% higher than India’s 81. By 2004, the situation was reversed, with Bangladesh’s infant mortality rate (38) 21% lower than India’s (48). 

Three main factors seem to explain the dramatic improvements. 

First, economic empowerment of women through employment in the garment industry and access to microcredit transformed their situation. The vast majority of women in the garment industry are migrants from rural areas. This unprecedented employment opportunity for young women has narrowed gender gaps in employment and income. The spread of microcredit has also aided women’s empowerment. Grameen Bank alone has disbursed $8.74 billion to 8 million borrowers, 95% of them women. According to recent estimates, these small loans have enabled more than half of borrowers’ households to cross the poverty line, and new economic opportunities have opened up as a result of easier access to microcredit. Postponed marriage and motherhood are direct consequences of women’s empowerment, as are the effects on child survival. 

Second, social and political empowerment of women has occurred through regular meetings of women’s groups organized by nongovernmental organizations. For example, the Grameen system has familiarized borrowers with election processes, since members participate in annual elections for chairperson and secretaries, centre-chiefs and deputy centre-chiefs, as well as board member elections every three years. This experience has prepared many women to run for public office. Women have also been socially empowered through participation in the banks. A recent analysis suggests much better knowledge about health among participants in credit forums than among nonparticipants. 

Third, the higher participation of girls in formal education has been enhanced by nongovernmental organizations. Informal schools run by the nongovernmental organization BRAC offer four years of accelerated primary schooling to adolescents who have never attended school, and the schools have retention rates over 94%. After graduation, students can join the formal schooling system, which most do. Monthly reproductive health sessions are integrated into the regular school curriculum and include such topics as adolescence, reproduction and menstruation, marriage and pregnancy, family planning and contraception, smoking and substance abuse, and gender issues. Today, girls’ enrolment in schools exceeds that of boys (15 years ago, only 40% of school attendees were girls). Women’s empowerment has gone hand-in-hand with substantial improvements in health services and promotion. With injectable contraceptives, contraceptive use has surged. Nearly 53% of women ages 15–40 now use contraceptives, often through services provided by community outreach workers. BRAC also provided community-based instruction to more than 13 million women about rehydration for children suffering from diarrhoea. 

Today Bangladesh has the world’s highest rate of oral rehydration use, and diarrhoea no longer figures as a major killer of children. Almost 95% of children in Bangladesh are fully immunized against tuberculosis, compared with only 73% in India. Even adult tuberculosis cases fare better in Bangladesh, with BRAC-sponsored community volunteers treating more than 90% of cases, while India struggles to reach 70% through the formal health system.

Article taken from UN HDI Report by Ms Anita Rego.

Engaging UK Citizens in the #post2015 development agenda has important implications both home and away. Let’s take a look at Bradford…

Becca Degan, UK 

“In the early years the focus remains on reducing child poverty, improved housing, improved nutrition and lifestyles for women and their children… In addition, ensuring access to free high quality early education and childcare for all children including those with disabilities remains a key focus.” ¹

Reading this description of health priorities, reducing poverty, ensuring access to education for all, where would you assume the author was describing?

This is an extract from Bradford City Council’s 2012 Public Health Report. In 2010 27.1% of children in Bradford were living in poverty, compared to the national average of 21.9%. It has one of the highest rates of infant mortality across England, with the majority being from deprived areas². A response to these statistics has seen the launch of a number of projects, including Born in Bradford, a project that has the potential to help those much further afield than Bradford due to its focus on equality.

As the post Millennium Development Goals (MDGs) are being discussed, I think child and maternal health in Bradford provide a good example of how these goals can be made truly universal. Post 2015 goals should have a greater focus on inequality and the use of disaggregated measures, committing governments to tackling inequality, in areas such as Bradford, as well as in cities and countries more traditionally considered as experiencing poverty. International development agendas could be seen as an opportunity to engage in the worldwide community to figure out and action the best ways for all of us to help those in poverty, in our own neighbourhoods, towns and cities in the UK, as well as those on other continents.

Encouraging our politicians to focus on and commit to tackling inequalities has the potential to benefit people worldwide. Inequality has been a major barrier to achieving the current MDGs, despite broad success across several goals, many of the world’s poorest or most vulnerable have made little or no development progress over the past fifteen years and inequalities are now greater than ever³.

Bradford City Council has drafted their Health and Wellbeing Strategy for 2013-2017 and there first goal is to ‘Give every child the best start in life in the Bradford district’, this is determined as important due to the high levels of child poverty and infant mortality in Bradford. Their strategy also calls for ‘a healthy standard of living for all’, stating that the gap between the richest and the poorest parts of Bradford is greater than the gap in most other Local Authority areas⁴.

In the post 2015 global agenda we need to address issues that are truly universal, working together to ensure that those across the globe who are most vulnerable are not forgotten about and left behind, regardless of whether they live in a rich or poor nation. These goals should be and could be used by citizens in the UK as well as globally to pressure our governments to achieving goals that have been internationally ratified.

References:

1.      http://www.bradford.nhs.uk/wp-content/uploads/2011/08/Public-health-annual-report-2012.pdf

2.      http://www.chimat.org.uk/resource/browse.aspx?RID=101658

3.      http://results.org.uk/our-issues/mdgs/prioritising-inequality-post-mdgs

4.      http://www.bradford.gov.uk/NR/rdonlyres/D5030F5E-BD46-45F5-9724-B71A2F1BB17A/0/DraftHealthandWellbeingStrategy.pdf

About the author:

Having recently completed an MA in Globalisation and Development I am looking to develop my knowledge of global issues, to try and influence policy makers on topics that I am passionate about. I currently work in the health sector in pursuit of a career in public health policy and am particularly interested in the role that social media has on engaging citizens with policy.